04/09/2013 07:45
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TO:
7028705311
THE
VACCINE
CENTER
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LABCORP LCLS
BULK
TO
7028705311
LABCORP
PAGE
05/08
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Th~
Vaccine Center
L:lballlltor)'
I'PQr•
nc
ITI'Ir
LabCorp
Pho~ni.x
3930
E WatkiM Suite 300
Phoenix AZ 85034
7251
Phone·
602-4S4~8000
Spocillie NU111ber
I
ParleotiD
C ot~ttol
Nlllnbet
I
Accoum Number
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094.-195-1327-0
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27321550
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The
vaccine Center
Ji'~qont
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500
E
Windmill
Lane
ste
115
702-540-9626
LAS
VEGAS
NV
89123
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(Y/MID)
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44/07/00
09/04/68
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BAKTARI,J
Tests
Oro«•d
~R+Ct/GC
NAA+H~sAg+HSV2 Iq.,,;
HCV
Antibocty
l
'I I S~S
~SUL Il
;FLAG UJil tTS
R~I'EREN'CI :
lN'l:~lVAL
IJUI
I
RPR+Ct/GC
NAA+HBsAg+aSV2(Ig
•••
BBsAg
scre i n
Negative Negative
01
RPR
·Non
Reactive
Non
:Reactive
01
HIV
1 0 2
Abs-ICMA
01
HIV
l/0/2
Abs-Inde~
Value
<1.
00
<1.
00
01
Index Value:
Specimen
reactivity relative
to
the
negative
cutoff.
HIV
l/0/2
Abs, Qual
'Non
Reactive
Non
Reactive
01
Chlamydia
t:rachomatis,
NAA
'
Negative Negative
01
Neisseria
gono~rhoeae,
NAA
,Negative
Negative
01
Please
note:
01
Acceptable
specimens
for
this
test
are
male
urethral
swab,
endocervical
swab
and
liquid
based
pap specimens,
vaginal
swabs
in
APTIMA
transports
and
first
void
urine.
see
online
Directory
of
services
for
test
number
for
rectal
and
pharyngeal
specimens.
HSV
2
gG,
Type
Spec
<:0.91
index
0.00
0.90
02
HCV
Antibody
Hep
C
Virus
Ab
I
SMITH,
GAVIN
04/09/13
06%14 ET
Negative
<:0.91
Equivocal
0.91
-
1.09
Positive
~1.09
Note:
Negative
indicates
no
antibodies
detected
to
Hsv-2.
Equivocal
may
suggest
early infection.
If
clinically
appropriate,
retest at later
date.
Positive indicates
antibodies
detected
to
RSV-2;
coinfeation
with
HSV-1
cannot
be
excluded
without type
specific
tasting.
<0.1
s/co
ratio
Negative:
Indeterminate
Positiva:
0.0
-
0.9
<
0.8
o.a -
0.9
>
0.9
In
ordsr
to
reduce
the
incidence of
a
false positive
~esult,
the
CDC
recommends
that
all
a/co
ratios
between
1.0
and
10.9
be
confipmed
with
~dditional
01
094 195 1327 0
Seq#0719
I
FINAL
REPORT
Tbis
d<lCmn~nt
contains
riva~
and
<:<:m J.dentlal
))ea)th
mfonuation
pr¢l.«:led
by
state
and
federal
law.
Jfyoubave
ece~ved
thia
doomnentm
orror,
ple~se
c@
888-522-2677
Page
1
of
2
()2004-13
Labor:otoxy
Cajp<lrstion
of
Amc&a
®
Haldlngs
All
l_<igl lts
R~sernd
DOC
Ve-r:
1.49
04/0S/2013 07:45
04109 2013
6:15:2
AM
TO:
7028705311
THE
VACCINE
CENTER PAGE
05/08
Pe~ge
3
of
5
ROM:
LABCORP
LCLS BULK
TO:
7028705311
LABCORP
•
~ '1'
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' '
~~
SMITH GAVIN
The Vaccine Center
LabCorp Phoerux
3930 E Watkins Suite 300
Pho~
~85034
7251
P1tle11tN=
Phone·
602-454-8000
Sp~monNtllllbtf
094 195.;...1327 0
A.cl:oull
Umber
I
P•~omiO
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Control
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atnad
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27321550
CFS.27321550 Oo:l/04/13
00:00
04/0~/13
M
44/07/oO
09/04/oe
MSUL:r :
l t..ILG
tmus
RIBA
or
PCR
testing.
Ol
PD
:ta.bCor~;>
:Phoenix
Oir
Franlc
~yan
PhO
3930
~
watkin5
Suite
300,
PhQenix,
A~
S5034-72Sl
02
BN
LabCorp : Ourlington
Dir
William
F
Hancock,
M
1447
York
Court,
~urlington,
NC
27115-3361
~or
inquiries,
the
physician
ma.y
contact
aranch:
888 522 2677
Lab:
602-454~8000
SMITH,
GAVlN
04/09/13 06:14
ET
FINAL
REPORT
This document contains
pllV~te
and
confidonti.•l
b•aHl:)
lnfonnation
ro~ted
by
state and fodetallaw.
J f
you have
=~iv..d
th:\s
docum~nt
in
CIIW,
p ea~
call
8SS 5:U 2677
094 195 1327 0
Page
2
of
2
®:ZO(lil.-13
Laboratozy
Corporation
ilf
AmW-ca
< 1
Holdings
All
Right>;
R~serwd
DOCl
Vu:
1.49
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04/09/2013 07:45
7028705311
~LabCorp
labQ<aloly
Corporatloo
ol
Am"i~
.
·o
find the nearest
patient
ervice
center.
visit
www.
~bcorp.com
or
call
888-
ABCOF P
(888-522·2677).
lhe
Uscrine Center
§00
E Windmill Lant
Stt
115
lAS
UEGtS
MD
8912;
102-010-1911
NVU
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THE
VACCINE
CENTER
OFa.: OCall OMail
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PAGE
07/08
0800.15
Reier
to
Determining
Necessity
ot
ABN
Completion
on
reverse
.
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04 09 2013 07:45
7028705311
THE
VACCINE
CENTER PAGE
08 08
THE
V CCINE CENTER
And
Travel Medicine Clinic
onsent
or
Sexually Transmitted Disease Testing
I,
J
1
N
s
V\
\ .
-rt-1
(PRINT
NAME:},
hereby request
and
authorize
The
Vaccine
Center
(TVCTM)
physicians and/or its medical staff, and/or the other health care providers
have seen
or will
see
to
collect blood/urine sample for
analysis
of:
j(
HIV
':k
Herpes
:k
Gonorrhea
*
Hepatitis
B
Chlamydia
k
Hepatitis
c
t
Syphilis 1 understand
and
agree
that
these records will
be
disclosed and/or re-disclosed
to
The
Vaccine
Center staff
and
myself. understand that
in
the event
1
test positive
to
HIV,
Gonorrhea, Chlamydia and/or Syphilis,
The
Vaccine
Center
and
Travel Medicine
Clinic
(and all other clinics) are mandated
by
Nevada
State
Law
to report the results
to
the Southern
Nevada
Health District.
DISCLAIMER
Your
test
results
show
current
and
active
infections
only.
It is
recommended
to
repeat tests
in
3 weeks
and
3-6
months
if
you are at risk from
a
recent exposure. Incubation period
for
HIV:
3
months, Syphilis:
1-3
months,
Herpe
6-26
JkB.
Chlamydia' 1-3 week;, Gonorrheo:
2-3
da f.', Hepatais
B'
1-5 months, Hepatttis
c,
2-6
months.
INITIAL
HERE
I understand that payment today does not cover the cost
of
consultation with a clinician or treatment.
I
understand that
if
I
would like
to
meet with a
clinician
before
or
after testing that the cost
is
65
per visit.
COPIES
I
have
been
advised
that
I
am
entitled to receive a copy
of
this Authorization. Patient's
PRINTED
Name:
G_,...:....A.,;_\J~lNc__::__~-< ..:::..._fY\..,;....:.....1:.....l_:__:_ ~~------
Patient's
Date
of
Birth:
S.:...:(~f_(
___
f~
~ 1 CJ ._:k~~ =
Patient's
Social
Securtty
ber:.
@ o
I
1£:
Patient's
Signature:
--Jb,.~ ---~--J-~~--_,;;;:::::_
Today's
Date:
--'-1'1---'-- -lf
...;....a_= ..
~
J~....:..0::-... ....--1
..L___ ~
Witness
PRINTED
Name:
J4.t.Ckl
Q
n
15:0
Witness Signature ,
0
,1
)..
r
t\.{ _/t.,[>
Today'sDate'
#1/ J
Main
Office:
500 E Windmill Lane, Suite 115
Las Vegas,
Nevada
89123
Appointments & Walk-ins Available Phone:
702.870.1911 Fax: 702.870.5311
INWW.
vaccineoenter.com info@vaccinecenter.com
Northwest Location
2051
N
Rainbow Boulevard,
Suite
100
Las
Vegas,
Nevada 89108 Appointments
Walk-ins
Available
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